Moving Expenses - Related to the Relocation of Household/Personal Goods

UNIVERSITY OFWASHINGTON Request for Moving Expenses (A33)

Completed By Department

Employee's Name (Last, First, M.I.)	Social Security # _____ - ____ - ______
Title	Job Class	Appt. Start Date ___ / ___ / ___
UW Department
Department Contact (Last, First, M.I.)	Campus Box # 35	Campus Phone
Department Contact Email

Authorized Limits ($'s and/or weight)

Limit for household goods	Budget #	Limit for meals, lodging, mileage, temp. housing, etc.	Budget #
Purchase Requisition #		Purchase Requisition #

Completed By Employee

Estimated $ Value of Household Goods	Requested Pick-up Date
My move will be coordinated by the State movers contract. __________Yes __________No	I'll move myself and be reimbursed. __________Yes __________No
Current Home Address Street, Apt. City, State, Zip Country	Current Phone #'s HM WK
Destination Home Address (if known) Street, Apt. City, State, Zip Country

EMPLOYEE AGREEMENT
       I acknowledge receipt of a copy of the Moving Expense Regulations and Guide and agree to pay all costs that are in excess of those allowable costs set forth in the guide. I hereby authorize the amount of excess cost to be deducted from my next salary payment if I do not provide the state with payment for any portion of this household move which by regulation must be paid by the employee. I understand that payment is due within (30) days from the date of notice of excess charges.
       If I terminate or cause temination of my employment from the University of Washington within one year (nine months for nine month faculty) of my appointment effective date, I agree to reimburse all previously paid moving costs to the University of Washington and further authorize the University to withhold any sums due me as part or full repayment of such costs in conformance with RCW 43.03.

Date	Employee Signature (Original, no fax or copies)

APPROVALS

Date	Chair or Department Head
Date	Dean or Division Head
Date	Academic Personnel